BEFORE THE DISTRICT FORUM:KURNOOL
Present: Sri K.V.H.Prasad, B.A., LL.B., President
Sri R.Ramachandra Reddy B.Com., LL.B., Member
Tuesday the 16th day of May, 2006
C.C. No.172/2005
Thirupal Reddy, S/o. Late Nagi Reddy, Aged 42 years, Business, Hindu,
Venkatachalam Colony, Nandyal, Kurnool Dist.
. . . Complainant
-Vs-
1. The Branch Manager, The New India Assurance Co. Ltd.,
H.No. 25/430-A1, Bus Stand Road, Nandyal, Kurnool Dist.
2. The Managing Director, Good Health Plan Limited,
House No 8-2-1/B/1, S.V.R Towers, 4th Floor, Srinagar Colony, Panjagutta, Hyderabad - 500082.
. . . Opposite parties
This complaint coming on this day for Orders in the presence of Sri M.L. Srinivasa Reddy, Advocate, Kurnool for complainant and Sri Mohammed Ishaq, Advocate, Kurnool for opposite party No.1 and opposite party No.2 called absent set exparte, and stood over for consideration, till this day, the Forum made the following.
O R D E R
(As per Sri. K.V.H.Prasad, Hon’ble President)
1. This case of the complainant is for a direction on the opposite parties to pray to the complainant Rs.2,33,935/- towards incurred medical expenditure with interest @ 18% per annum from the date of the time, Rs.20,000/- as compensation for mental agony alleging the deficiency of service on the part of the opposite parties in rejecting the medical claim preferred under policy No.611502/48/05/75014 assured for Rs.3,00,000/-, for the treatment of the complainant undergone from 29-8-2005 to 27-9-2005 incurring Rs.2,33,935/-.
2. The case of the complainant in brief is that he obtained individual medi claim i.e. Hospitalization and Domiciliary hospitalization benefit policy No.611502/48/05/75014 covering Rs.3,00,000/- for the period 27-6-2005 to 26-6-2006 from the opposite party No.1 and as per its terms medical expenditure spent by the policy holder upto Rs.3,00,000/- will be paid by insurer and opposite party No.2 is a third party administrator to act on behalf of the opposite party No.1 for processing all claims relating to said medi claim policy and the complainant has undergone treatment for chest pain and breathlessness complaint from 29-8-2005 onwards till 27-9-2005 (date of discharge) at Gupta Hospital, Nandyal and operation at Usha Mullapudi Cardiac Centre, Hyderbad and incurred medical expenditure of Rs.2,33,935/- and the opposite parties rejected his claim on the pretest of complainant having a pre existing disease and suppression of the same while obtaining the policy.
3. In pursuance of the receipt of the notice of this Forum as to this case of the complainant, while the opposite party No.2 remained absent and set exparty, the opposite party No.1 contested the case filing written version denying its liability to the claim of the complainant.
4. The written version of the opposite party No.1 even though doesn’t deny the complainant as its policy holder but allege the complainant is known diabetic and having knowledge of his pre existing diseases did not declare the same at the time of obtaining said policy and so not entitle to the medi claim under condition No.4.1 of the policy terms and conditions and hence for want of any deficiency of service and any bonafid cause of action seek the dismissal of the complaint case with costs.
5. In substantiation of the contentions while the complainant side has relied upon the documentary record in Ex.A1 to A19 and his sworn affidavit and replies to the interrogatories, the opposite party side has taken reliance on documentary record in Ex.B1 and B2 and its sworn affidavit and replies to the interrogatories.
6. Hence the point for consideration is whether the complainant has made out the alleged deficiency of service on the part of the opposite parties and there by the liability of the opposite parties to make good of the complainant’s claim.
7. The Ex.A1 is the said medi claim policy No.611502/48/05/75014 along with receipts of its premium standing on the name of the complainant commencing from 27-6-2005 assuring the reimbursement of incurred medical expenditure of the complainant to the extent of Rs.3,00,000/- during the period of said policy commencing from 27-6-2005 and concluding by 26-6-2006. As the opposite parties are not denying the said status of the complainant under it as policy holder the Ex.A1 remains conclusively proved on complainant’s side.
8. The Ex.A2 is the laminated identification card containing the photo of the complainant issued by the opposite party No.1 to the complainant under good health plan limited in reference to the policy under Ex.A1. In the light of non denial of the status of the complainant as policy holder under Ex.A1 – The Ex.A2 remains as annexure identity card to the status of the complainant.
9. The Ex.A18 is the claim form of the complainant for the incurred medical expenditure covered under Ex.A4 to A17 i.e. medical reports and bills, and the Ex.A19 is the repudiation of said claim of the complainant as the later is a known diabetic and history and clinical findings are showing of old inferior wall M1 and the claim on account of pre existing disease.
10. The Ex.A3 discharge advice issued by Dr. A.Venu Gopal Gupta says the deduction of Hyper Blycemia at the time of final diagnosis and CAD old inferior wall M1 (unstable angina now) and with any past history of similar chest pain and not a known diabetic / hyper tensive or smoker, no habit of drug allergy / bleeding diathesis / conversions/ APD / Recent surgery or anemia jaunice / Cynosis / Ciebbing / LN / Odema and referal to higher cardiac centre for coronary agio-plan for further management as patient showed uneventful recovery and restricted activity. Hence there appears any material in Ex.A3 to feel that the complainant was with any pre existing diseases history which must have lead him to the treatment he has undergone for reimbursement of which the claim was preferred.
11. The Ex.A4 is the medical reports running in 7 pages covering litid profile, 2D Echo Cardiogram Report. The Ex.A14 is discharge summary issued by Usha Mullapudi Cardiac Centre, Hyderabad. The Ex.A15 is the coronary angiogram report and its other annexure reports. They do not envisage any close proximity of any pre existing diseases of the complainant. Nor the opposite party side has placed any such cogent authenticated material by which any pre existing disease of the complainant could be inferred and believed as a reason or promoting cause for the treatment the complainant has undergone and preferred the claim for reimbursement of incurred medical expenditure assured under the policy. The Ex.B1 is the mere rules and conditions of Ex.A1 policy and the Ex.B2 is the proposal form, which the complainant has submitted to the opposite party at the time of obtaining said policy. Mere existence of a condition in Ex.A1 providing the circumstance for repudiation is not sufficient as it could be availed only on existence of said condition in the case of the complainant. In the absence of any such cogent material making out the complainant suppressing of his any pre existing disease at the time of obtaining the Ex.A1 policy, the repudiation of the complainant’s claim by the opposite parties remains not only improper but also amounts to deficiency of service.
12. The Ex.A5 is the bill receipt issued by Gupta Hospital in favour of the complainant for Rs.3,550/- as charges collected under various heads for the treatment given by the complainant. The Ex.A6 are a bunch of 6 bills for purchase of medicines prescribed by Dr.A.Venugopal Gupta to the complainant. They are totaling to Rs.4,381.50ps. The Ex.A7 is the bill issued by Apollo Medical Centre, Kurnool to the complainant on being reffered by Dr.A.Venugopal Gupta, envisages a receipt of Rs.885/-towards lab services and other miscellaneous charges. The material in Ex.A8, A10 and A11 envisages the advance amount paid by the complainant to Usha Mullapudi Cardiac Centre, Hyderabad totaling to Rs.2,24,919/-and the Ex.A12 shows the details of the bill amounting to said Rs.2,24,919/- received in advance from the complainant
under Ex.A8, A10 and A11 and the Ex.A13 stands at a consolidated bill for the above payment of the complainant. In the absence of any rebuttal from the opposite party side for the supra stated entitled claims of the complainant envisaged under Ex.A5 to A8, A10 to A13 the complainants incurred medical expenditure is amounting to Rs.2,33,735.50 ps (i.e. Rs.3,550 (Ex.A5) + Rs.4,381.50ps (Ex.A6) + Rs.885 (Ex.A7) + Rs.2,24,919 (vide Ex.A8, A10 to A13) ) and not of Rs.2,33,935/- as claimed in the complaint.
13. As the repudiation of the claim by the opposite parties in the absence of any cogent material as to any pre existing disease of the complainant by the time of obtaining the policy, as is not only remaining improper but also amounting to deficiency of service ensuing mental agony to the complainant, the complainant is entitled not only to the supra stated incurred medical expenditure of Rs.2,33,735.50ps being covered under the Ex.A1 policy but also to an amount of Rs.20,000/- towards compensation for mental agony at the deficiency of service of opposite parties and costs of litigation.
14. In result of the above discussion the complaint is allowed directing the opposite parties No.1 and 2 jointly and severally to pay the award amount of Rs.2,53,735.50 ps ( Rs.2,33,735.50ps+Rs.20,000) within a month of the receipt of this order in default the opposite parties shall liable jointly and severally to pay the awards amount of Rs.2,53,735.50ps with interest at 12% per annum from date of repudiation till realization.
Dictated to the Stenographer, transcribed by him corrected and pronounced by us in the Open Forum this the 16th day of May, 2006.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant: Nil For the opposite parties: Nil
List of Exhibits Marked for the complainant:-
Ex A.1 Medi claim policy No. 611502/48/05/75014.
Ex A.2 Medi claim card issued by opposite party No.2.
Ex A.3 Discharge advice issued Dr A. Venugopal Gupta M.D,
Ex A.4 Medical reports of complainant (number of 7 papers) Aswani Hospital
(Gupta Hospital).
Ex A.5 Bill receipt, dt 2.9.2005 issued by Gupta Hospital to the complainant.
Ex A.6 Six Medical bills total Rs.4,381/- (Rs.150/-+ 804/- 280/- +
1086/-+ 938/-+1123/-).
Ex A.7 Three bills issued by Apollo Medical Centre, Kurnool.
Ex A.8 Advance Slip for Rs.7,500/- issued by Usha Mullapudi Cardiac Centre,
Kurnool.
Ex A.9 Estimation Certificate dt 23.9.2005 issued by Usha Mullapudi Cardiac
Centre for Rs.2,25,000/-.
Ex A.10 Advance Slip dt 23.9.05 for Rs.2,15,000/- issued by Usha Mullapudi
Cardiac Centre.
Ex A.11 Advance Slip dt 27.9.05 for Rs.2,419/- issued by Usha Mullapudi
Cardiac Centre.
Ex A.12 Detailed bill, dt 27.9.2005 issued by Usha Mullapudi Cardiac Centre to
the complainant for Rs.2,24,919/-.
Ex A.13 Consolidated bill dt 27.9.2005 issued by Usha Mullapudi Cardiac
Centre for Rs.2,24,919/-.
Ex A.14 Discharge Summary Card issued by Usha Mullapudi Cardiac Centre (1
to 4 pages).
Ex A.15 Medical Report issued by Usha Mullapudi Cardiac Centre (1to 8 pages).
Ex A.16 IP Admission Slip sent by fax to opposite party No.2.
Ex A.17 Bill for phoning to 08514-242038 of opposite party No.1 dt 23.9.2005.
Ex A.18 Claim Form, dt 27.9.2005 submitted to opposite party No.2.
Ex A.19 Repudiation letter issued by opposite party No.2, dt 13.10.2005 to the
complainant.
List of Exhibits Marked for the opposite parties:
Ex B.1 Rules and conditions Ex A.1 policy.
Ex B.2 Proposal Form.
MEMBER PRESIDENT
Copy to:-
1.Sri M.L. Srinivasa Reddy, Advocate, Kurnool.
2.Sri Mohammed Ishaq, Advocate, Kurnool.
3. The Managing Director, Good Health Plan Limited, House No 8-2-1/B/1,
S.V.R Towers, 4th Floor, Srinagar Colony, Panjagutta, Hyderabad – 500082.
Copy was made ready on:
Copy was dispatched on:
Copy was delivered to parties:
